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Severe hypertension without features requiring same-day referral — MRCEM SBA MCQ

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EasyCardiovascular emergenciesSevere hypertension without features requiring same-day referralMRCEM SBA

A 56-year-old man attends the emergency department after a high blood pressure reading at a pharmacy. After resting, two correctly measured readings are 204/124 mmHg and 200/122 mmHg. He has no chest pain, breathlessness, confusion, focal neurological symptoms or other acute symptoms. Fundoscopy shows no retinal haemorrhages or papilloedema. His ECG, creatinine, estimated glomerular filtration rate and urine albumin:creatinine ratio show no target organ damage. He can attend prompt follow-up. What is the most appropriate management and disposition?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Discharge without starting treatment today and repeat clinic blood pressure within 7 days.

His repeated blood pressure meets the threshold for severe hypertension, but the reading alone does not establish a hypertensive emergency. He has neither symptoms or retinal findings requiring same-day specialist assessment nor evidence of target organ damage on the investigations provided. NICE recommends confirming the diagnosis in this situation by repeating clinic blood pressure within 7 days; ambulatory or home monitoring is an alternative if clinical review also occurs within 7 days. **B** is therefore the best plan. ([nice.org.uk](https://www.nice.org.uk/guidance/ng136/resources/hypertension-in-adults-diagnosis-and-managementpdf-66141722710213)) **A** would be appropriate to consider in an acute hypertensive emergency requiring monitored treatment, not for this asymptomatic finding. **C** is attractive because the pressure is markedly raised, but same-day specialist assessment is indicated if, for example, retinal haemorrhage, papilloedema or life-threatening symptoms are present. **D** might be appropriate if target organ damage had been identified: NICE then advises considering treatment immediately without awaiting out-of-office confirmation. **E** uses an acceptable method of confirmation, but its four-week delay to clinical review misses the recommended seven-day interval. ([nice.org.uk](https://www.nice.org.uk/guidance/ng136/resources/hypertension-in-adults-diagnosis-and-managementpdf-66141722710213))

Reference: NICE NG136, Hypertension in adults: diagnosis and management, recommendation 1.5.1 (26 February 2026) — https://www.nice.org.uk/guidance/ng136/resources/hypertension-in-adults-diagnosis-and-managementpdf-66141722710213 NICE NG136, Hypertension in adults: diagnosis and management, recommendations 1.3.3 and 1.5.2 (26 February 2026) — https://www.nice.org.uk/guidance/ng136/chapter/recommendations